Shared Cultural Values Influence Mental Health Help-Seeking Behaviors in Asian and Latinx College Students

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Journal of Racial and Ethnic Health Disparities

Shared Cultural Values Influence Mental Health Help-Seeking
Behaviors in Asian and Latinx College Students
E. Zhou 1 & Y. Kyeong 1 & C. S. Cheung 1 & K. J. Michalska 1

Received: 11 April 2021 / Revised: 22 May 2021 / Accepted: 24 May 2021
# The Author(s) 2021

The current study sought to understand the influence of cultural values on mental health attitudes and help-seeking behaviors in
college students of diverse ethnic backgrounds. Asian and Latinx college students (N = 159) completed an online survey in which
they reported on their adherence to cultural values as measured by ethnicity-specific cultural values and general attitudes towards
mental health. Factor analysis revealed two common factors of cultural values irrespective of ethnicity: Interdependent
Orientation (IO) and Cultural Obligation (CO). Regardless of ethnicity, the more students endorsed IO values, the less likely
they were to perceive a need for mental health treatment. IO value adherence was also predictive of more negative attitudes
towards mental health. CO values were not predictive of perceived need or help-seeking behaviors. Findings highlight the
importance of understanding shared cultural values across ethnic-racial groups and considering how the multidimensionality
of culture may help explain shared mental health behaviors crossing lines of ethnic group membership.

Keywords Culture . Values . Help-seeking . Mental health attitudes . College students

National rates of student mental health diagnoses and service            this study examined whether family- and group-oriented di-
utilization are increasing on college campuses across the USA            mensions of cultural values that are shared among Asian and
[1], yet glaring racial-ethnic disparities exist in treatment-           Latinx college students are associated with perceived need for
seeking behavior and receipt of psychological services [2].              mental health treatment and mental health help-seeking, above
Despite higher rates of psychological distress reported by               demographic characteristics. A focus on shared cultural values
Asian and Latinx students in particular [2, 3], these students           can help mental health service providers understand barriers to
access campus mental health care services at lower rates than            help-seeking more completely without assigning blame to any
their non-Latinx White peers [4, 5]. Of course, ethnic group             specific ethnicity or culture.
membership alone does not determine whether a student will
seek mental health services. Other underlying factors need to
be examined to understand how members of these groups
                                                                         Familism and Mental Health Behaviors
approach available campus resources. We focus here on the
role of cultural values pertinent to these ethnic groups on
                                                                         Individuals from Latinx [12] and Asian [13] cultures value
stude nts’ mental he alth help-se eking b ehav io rs,
                                                                         familism, or the duty to assist, support, and respect one’s fam-
complementing the extensive work on external barriers to
                                                                         ily. Research conducted separately in both groups has
seeking treatment including language or financial resources
                                                                         established associations between high levels of familism and
[6–9]. Though existing work has drawn connections between
                                                                         improved well-being via supportive family ties [14, 15].
cultural values and mental health attitudes among both Asian
                                                                         However, because family is viewed as an extension of the self
and Latinx groups, the present work furthers the literature by
                                                                         in both cultures and the needs of the family are valued above
examining shared values across groups [10, 11]. Specifically,
                                                                         the needs of the individual [16, 17], this can also imply that if
                                                                         an individual is experiencing psychological distress, then
                                                                         shame or stigma faced by that individual may also be experi-
* K. J. Michalska
                                                                         enced by the family. In line with this notion, acknowledging
                                                                         mental health problems is sometimes perceived as a failure
    Department of Psychology, University of California Riverside, 900    shared by the family and extended kinship group in these
    University Ave. Riverside, California, CA 92521, USA                 cultures [18, 19]. Familism therefore may foreshadow
J. Racial and Ethnic Health Disparities

unwillingness to seek professional treatment for mental illness   those of European heritage in their appraisals of negative emo-
[20, 21]. Familism in Latinx households has also been asso-       tions, deeming them more undesirable and inappropriate to
ciated with increased informal and religious avenues of help-     experience and express [32]. Stigma and shame, in conjunc-
seeking for mental health care but not specialty mental health    tion with viewing the family as an extension of the self, may
service use [22]. Ultimately, even though familism can be         lead to resistance towards mental health treatment-seeking, as
protective for mental health of youth from Asian and Latinx       acknowledging a need for mental health treatment may reflect
backgrounds, it may diminish some forms of mental health          poorly on the individual and their family. Both Asian and
help-seeking behaviors in these youth. Of note, previous work     Latinx groups value the avoidance of shame [33, 34], and
has observed gender differences in the associations between       seeking treatment for mental health issues may be perceived
familism and mental health outcomes among individuals of          as particularly shameful. To avoid bringing shame to them-
Asian and Latinx backgrounds, with women reporting poorer         selves and their families, Asian and Latinx college students
psychological health than men, despite greater levels of fam-     may therefore shy away from initiating mental health treat-
ilism and support [14]. A study by Sanchez and Atkinson           ment [35, 36]. One particularly alarming example of the ad-
similarly finds that though strong Mexican-American cultural      verse effects of stigma was documented among a sample of
commitment was related to lesser willingness towards self-        suicidal Latina adolescents, who viewed suicide as a viable
disclosure in counseling overall, females were more willing       solution to alleviate undue burdens of shame on their families
to use counseling services than males [23]. In another study      [37].
with Asian college students, Gim, Atkinson, and colleagues           Studies that have directly evaluated links between socio-
also observed a relationship between willingness to seek          cultural values and mental health help-seeking stigma have
counseling and both gender and acculturation [24].                yielded mixed findings. Even though several such studies find
However, though the gender difference was consistent such         positive associations between Asian cultural values and stig-
that women were more willing to seek counseling than men,         ma, not all indicate that stigma is directly relevant to help-
the relationship with acculturation was not, where by those       seeking behavior [38, 39]. For example, Kim & Zane (2016)
individuals who reported lower levels of acculturation were       found that even though Asian American students perceived
more open to professional help-seeking than those who report-     greater barriers to help-seeking than non-Latinx White stu-
ed higher levels of acculturation. The finding that less accul-   dents, both groups showed an inverse relationship between
turated Asian students were more willing to see a counselor       stigma and help-seeking intentions [40]. Likewise, in the lit-
directly contradicted a previous study from Atkinson and          erature on Latinx cultural values and stigma, adults report that
Gim, which found that in a sample of Asian students, those        stigma resulting from cultural expectations discourages them
most acculturated held the most positive attitudes towards        from admitting need for mental health help and adhering to a
mental health services [25]. Given these mixed findings, it is    treatment plan, though less is known about its relationship to
important to consider how cultural values and gender might        seeking psychological services in college students [30]. Some
independently and interactively predict mental health behav-      researchers find a stronger relationship with Latinx cultural
iors across different groups in the college environment. To our   values and stigma in older adults and a weaker one in college
knowledge, no study has examined this question among Asian        students, but it is yet unclear how this relationship might in-
and Latinx college students.                                      fluence mental health help-seeking [41, 42]. Collectively,
                                                                  these findings highlight both the complex role of cultural
                                                                  values in mental health contexts and the need for additional
Mental Health Attitudes as Barriers to Mental                     research in culturally diverse settings.
Health Help-Seeking
                                                                  Perceptions of Mental Illness
Mental Health Stigma
                                                                  Beyond stigma, diminished rates of help-seeking in both
One prominent psychological barrier to mental health help-        Asian and Latinx college students may also stem from differ-
seeking is mental health stigma, which manifests primarily        ing perceptions of what constitutes a mental illness warranting
in social and self-stigma, or negative public attitudes towards   professional treatment. Both ethnic groups experience soma-
mental illness and the internalization of these public percep-    tization, reporting physical ailments in lieu of mental illness
tions [26, 27]. Asian and Latinx students generally report        [43, 44]. The tendency towards somatization may inadvertent-
greater stigma about mental illness and mental health help-       ly stem from stigma, in that it is more culturally acceptable to
seeking behaviors compared with non-Latinx White students         experience and seek treatment for physical ailments over men-
[28, 29], which may in part be due to mental illness being        tal ones [45]. In fact, when somatic symptoms emerge, Asian
considered an admission of emotional weakness [30, 31].           and Latinx individuals often seek out help from medical doc-
Students of both Asian and Latinx heritage also differ from       tors or alternative healers instead of psychological
J. Racial and Ethnic Health Disparities

professionals for treatment [46–49], potentially leading to        Asian or Latinx in 2019, respectively. All participants were
greater rates of misdiagnosis [50]. Additionally, those Asian      recruited from the psychology department participant pool.
and Latinx individuals who seek professional psychological         Consent was obtained from all participants via electronic ac-
treatment often present with more severe symptoms and tend         knowledgment. Students were awarded course credit for par-
to experience problems for a prolonged period of time prior to     ticipation. Study approval was obtained from the university
treatment, suggesting that the threshold for seeking mental        Institutional Review Board.
health services is higher for them [51–53]. Based on the men-
tal health attitudes largely shared by Asian and Latinx college    Measures
students, they may be similarly deterred from making initial
contact with on-campus mental health service providers. Yet,       Cultural Values
scant research has examined the shared cultural values that
may influence mental health utilization behaviors across           Asian Values Scale - Revised (AVS-R) The Asian Values Scale-
ethnic-racial groups.                                              Revised (AVS-R) [55] is a 25-item measure assessing en-
                                                                   dorsement of values associated with the Asian culture short-
                                                                   ened from the original 36-item measure [56]. Participants in-
The Present Study                                                  dicated the extent to which each statement applied to them (1
                                                                   = strongly disagree; 4 = strongly agree), with higher scores
Mental health treatment-seeking behaviors of Asian and             indicating greater adherence to Asian cultural values.
Latinx students have largely been examined within-group,           Example items include “One should consider the needs of
even though different studies find that similar cultural values    others before considering one’s own needs” and “One should
influence help-seeking behaviors in both Asian and Latinx          not deviate from familial and social norms.” The scale has
youth [6, 35]. Despite significant heterogeneity across and        demonstrated strong reliability and validity in past research
within cultures, we contend that some shared cultural values       in university student samples [55], and Cronbach’s alpha in
may lead to less utilization of campus mental health services      this sample was .81.
by Asian and Latinx students. Importantly, we do not put forth
that Western mental health services are the only intervention      Latino Values Scale (LVS) Participants also completed the 35-
of choice for all students. However, given that available treat-   item Latino Values Scale (LVS) [57] measuring endorsement
ments in university settings in the USA are traditional Western    of values associated with the Latinx culture. Participants indi-
psychological treatment services, it is important to more com-     cated the extent to which each statement applied to them (1 =
prehensively understand students’ engagement with such pro-        strongly disagree; 4 = strongly agree), with higher scores in-
grams. The present study therefore aimed to examine shared         dicating greater adherence to Latinx cultural values. Example
relationships between cultural values, mental health attitudes,    items include “One’s family is the main source of one’s iden-
and mental health behaviors (perceived mental health               tity” and “One must not offend others.” The measure yields a
treatment need and help-seeking) in Asian and Latinx college       total score (LVS - Total) and two subscale scores (LVS –
students. Specifically, we tested (a) the extent to which cul-     “Cultural Pride” and LVS – “Familismo”). The scale has dem-
tural values endorsed by Asian and Latinx college students         onstrated strong reliability and validity in past research in
were shared, and how cultural values predicted (b) attitudes       university student populations [57]. We assessed adherence
toward mental health, and (c) perception of mental health          to Latinx values via the LVS - Total, for which the
treatment need and help-seeking behaviors, above ethnicity         Cronbach’s alpha in this sample was .89.
                                                                   Attitudes Towards Mental Health

Method                                                             Attitudes Towards Mental Illness (AMI) Mental health attitudes
                                                                   were assessed using 47 items adopted from two scales:
Participants                                                       Community Attitudes Toward Mental Illness (CAMI) [58]
                                                                   and Reported and Intended Behaviour Scale (RIBS) [59].
One hundred fifty-nine undergraduate college students (61%            The CAMI is a 40-item measure that assesses prejudice
female, 58.5% Asian, 41.5% Latinx, 55.3% first-year stu-           towards and exclusion of the mentally ill and tolerance/
dents) from a public university in Southern California com-        support for community care. Example items include, “One
pleted a six-section online survey hosted on Qualtrics. The        of the main causes of mental illness is a lack of self-
sample was representative of the demographic majority of           discipline and willpower” and “Mental illness is an illness like
the university and California broadly [54], with about 75.3%       any other.” Following prior recommendations (UK
of students and 54% of California residents identifying as         Department of Health Attitudes to Mental Illness
J. Racial and Ethnic Health Disparities

Questionnaire) [60], we retained 26 of the original 40 items       membership, all regressions controlled for ethnicity.
and added one item on employment attitudes. To facilitate          Participant gender was also included as a covariate to account
interpretation, negative items were reverse-coded, such that       for potential gendered cultural expectations, particularly
overall scores indicated positive attitudes towards mental ill-    pertaining to familism. In logistic regression models examin-
ness. Cronbach’s alpha for the CAMI in this sample was .86.        ing mental health behaviors, mental health attitudes were co-
   The RIBS is an 8-item instrument that measures both re-         varied to isolate the unique effects of cultural values on mental
ported engagement (e.g., “Are you currently living with, or        health behaviors.
have you ever lived with, someone with a mental health prob-
lem?”) and intended engagement (e.g., “In the future, I would
be willing to live with someone with a mental health prob-         Results
lem”) with individuals with mental health problems. To mea-
sure students’ mental health attitudes, four items specifically    Descriptive statistics and zero-order correlations among all
assessing intended engagement were used. Cronbach’s alpha          study variables are presented in Table 1. Overall, even though
for the RIBS in this sample was .88.                               Asian and Latinx values were correlated, both Asian and
   Both the CAMI and the RIBS scales were scored based on          Latinx students endorsed values in the Latinx values scale
agreement with correct or non-stigmatizing statements on a 5-      (M = 2.50, SD = 0.32) to a greater extent than those in the
point Likert scale (1 = strongly disagree; 5 = strongly agree).    Asian values scale (M = 2.35, SD = 0.31), t(158) = −8.61, p <
Because of substantial correlation between the two scales (r =     0.001. An independent-samples t-test revealed that Asian stu-
0.65, p < 0.001), a composite score was used. Low scores on        dents endorsed Asian values significantly more (M = 2.43, SD
the AMI composite score correspond to negative attitudes, and      = 0.27) than did Latinx students (M = 2.24, SD = 0.33), t(157)
high scores correspond to positive attitudes. Cronbach’s alpha     = 3.91, p < 0.001; there was no significant difference between
for the composite score in our sample was .89.                     groups in endorsement of Latinx values.

Perceived Mental Health Service Need and Help-Seeking              Analysis One: Common Factor Structure among Asian
Behavior Participants also responded to two multiple-choice        and Latinx Value Scale Items
questions about their own mental health needs and help-
seeking behavior. First, they responded either “Yes” or “No”       We first conducted an exploratory factor analysis, combining
to the question, “Do you feel you need mental health help?”        all items within both the AVS-R and the LVS into one model
Only those who responded affirmatively (n = 33) were then          to examine if latent variables were driving students’ response
asked to respond “Yes” or “No” to “Are you seeking                 patterns to both scales. To this end, we tested whether items
treatment?”                                                        loaded onto similar factors across the two groups from the
                                                                   pool of the 25 AVS-R items and 35 LVS items (Table S1).
Data Analytic Plan                                                     Our analysis revealed two underlying factors, which we la-
                                                                   beled Interdependent Orientation (IO, 7 items) and Cultural
The aims of this research were to determine whether some           Obligation (CO, 7 items). Items in the IO factor centered around
cultural values are shared among Asian and Latinx college          the importance of one’s family and in-group, whereas items in the
students and whether the degree of adherence to these values       CO factor focused on the importance of actively participating in
predicts students’ attitudes to mental health and their per-       and preserving one’s culture. Each of the factors was internally
ceived treatment need. To address the first aim, we conducted      consistent, with a Cronbach’s alpha of .77 for IO and .83 for CO.
an exploratory factor analysis of all items across Asian and
Latino value scales (AVS-R and LVS respectively, see
Table S1 for details), without an a priori hypothesis              Table 1 Descriptive statistics and zero-order correlations for key study
regarding the number of resultant factors. To address the sec-
ond aim, we performed a series of linear regression analyses to    Variable        M            SD           1       2              3
test whether AVS-R and LVS predicted students’ attitudes to
mental health. We then repeated these analyses, using the          1. LVS          2.50         0.32         -       0.75***        −0.29***
factors that emerged from our factor analysis as predictors of     2. AVS-R        2.35         0.31                 -              −0.49***
attitudes to mental health. To further shed light on the associ-   3. AMI          118.37       14.62                               -
ation between shared cultural values and students’ help-           Scaled LVS and scaled AVS-R scores have a possible range from 1 to 4;
seeking behaviors, we conducted hierarchical logistic regres-      AMI scores from 30 to 150
sions to test whether shared cultural values predicted students’   LVS Latino Values Scale, AVS-R Asian Values Scale-Revised, AMI
perceived treatment need and help-seeking behaviors. Given         Attitudes to Mental Illness
our focus on cultural values above and beyond ethnic group         ***p < 0.001
J. Racial and Ethnic Health Disparities

The two factors were positively correlated (r = 0.35, p < 0.001)       and their endorsement of cultural values predicted their per-
within the whole group and within each ethnic group (Asian: r =        ceived treatment need and their help-seeking behaviors. First,
0.39, p < 0.001, Latinx: r = 0.31, p = 0.01). Independent-samples t-   we tested whether students’ mental health attitudes (assessed
tests revealed no significant difference in mean scores of IO be-      via the AMI) and their endorsement of Asian values (assessed
tween participant groups (p = 0.73) and significantly greater mean     via the AVS-R) predicted the likelihood that they perceived a
scores on CO for Asian participants (M = 2.73, SD = 0.46) than         need for treatment or the likelihood of their mental health
Latinx (M = 2.58, SD = 0.51) participants, t(157) = 2.01, p < 0.05.    help-seeking behaviors. Results are shown in Table S6.
                                                                       After controlling for gender and ethnicity, AMI (OR = 1.05,
Analysis Two: Associations Between Value                               95% CI = [1.01, 1.08]) and AVS-R (OR = 0.08, 95% CI:
Endorsement and Attitudes to Mental Health and                         [0.01, 0.98]) predicted the likelihood that students perceived
Help-Seeking                                                           a need for mental health treatment. Specifically, for each unit
                                                                       increase in positive attitudes toward mental health, students
Next, we used three sets of hierarchical linear regressions to         were 5% more likely to perceive needing mental health treat-
examine the AVS-R, LVS, and the two shared factors derived             ment (β = 0.04, p = 0.01). In contrast, for each unit increase in
in the previous set of analyses, as predictors of students’ atti-      adherence to Asian values, students were 92% less likely to
tudes to mental health. A first set of hierarchical linear regres-     perceive a need for mental health treatment (β = −2.59, p <
sions examined the AVS-R as a predictor of attitudes towards           0.05). No significant predictors emerged with help-seeking
mental health. A second set of hierarchical linear regressions         behavior as the outcome variable (p > 0.27).
examined the LVS as a predictor of attitudes towards mental                The second set of logistic regressions examined whether
health. These analyses revealed that both the AVS-R and the            students’ mental health attitudes (assessed via the AMI) and
LVS added significantly to the prediction of students’ atti-           their endorsement of Latinx values (assessed via the LVS)
tudes to mental health (see supplementary materials).                  predicted the likelihood of their perceived treatment need
   A third set of hierarchical linear regressions examined the         and help-seeking behavior. Results are shown in Table S7.
two shared factors that emerged from our factor analysis (i.e.,        After controlling for gender and ethnicity, a main effect of
IO, CO) as predictors of students’ attitudes towards mental            AMI emerged in predicting the likelihood of perceived treat-
health. Using attitudes to mental health as the dependent var-         ment need (OR = 1.06, 95% CI = [1.02, 1.09]), whereby for
iable in two separate stepwise regressions, we entered ethnic-         each unit increase in positive attitudes towards mental health,
ity and gender in an initial step, either the IO factor or the CO      students were 6% more likely to perceive a need for treatment
factor in a second step, and factor × demographic interaction          (β = 0.05, p < 0.01). No significant predictors emerged with
terms in a third step.                                                 help-seeking behavior as the outcome variable (p > 0.26).
   In the analysis focusing on the IO factor, ethnicity and                The third set of logistic regressions examined whether our
gender were significantly associated with attitudes towards            two factors, IO and CO, predicted students’ perceived treat-
mental health, R2 = 0.12, F(2,156) = 10.91, p < 0.001. The             ment need and their help-seeking behavior. Ethnicity and gen-
IO factor significantly added to the prediction of attitudes           der were entered in step 1, AMI was entered in step 2, IO and
towards mental health, ΔR2 = 0.07, F(1,155) = 13.02 , p <              CO were entered in step 3, and factor × demographic interac-
0.001. IO was a significant inverse predictor of the AMI, after        tions were entered in step 4. Results showed main effects of
controlling for demographic variables. The step containing the         AMI (OR = 1.05, 95% CI = [1.02, 1.09]) and our IO factor
interaction term with the demographic variables did not add            (OR = 0.10, 95% CI = [0.02, 0.55]) on the likelihood of
significantly to the prediction of AMI (see Table S4).                 perceived treatment need. For each unit increase in positive
   In the analysis focusing on the CO factor, ethnicity and            attitudes to mental health, students were 5% more likely to
gender were significantly associated with attitudes towards            perceive a need for treatment (β = 0.05, p < 0.01).
mental health, R2 = 0.12, F(2,156) = 10.91, p < 0.001. The             Conversely, for each unit increase in IO, students were 90%
CO factor did not add significantly to the prediction of atti-         less likely to perceive a need for treatment (β = −2.30, p <
tudes towards mental health. Similarly, the interaction term           0.01). With help-seeking behavior as the outcome variable,
with ethnicity and gender did not add significantly to the pre-        only the interaction between IO and gender was significant
diction of attitudes towards mental health (see Table S5).             (OR = 0.00, 95% CI = [0.00, 0.74]) (Table 2). Because the
                                                                       main effect of IO was not significant and the sample size
Analysis Three: Associations Between Cultural Value                    reporting on help-seeking was small, we did not probe this
Endorsement and Perceived Treatment Need and                           interaction further.
Help-Seeking                                                               Our final analysis looking at the CO factor revealed only a
                                                                       main effect of AMI (OR = 1.07, 95% CI = [1.03, 1.10]) on the
Three sets of hierarchical logistic regressions were conducted         likelihood of perceived treatment need. For each unit increase
to examine whether students’ attitudes towards mental health           in positive attitudes to mental health, students were 7% more
J. Racial and Ethnic Health Disparities

Table 2     Logistic regressions with interdependent orientation predicting perceived need and help-seeking behavior

Outcome                           Perceived need                                                                             Help-seeking

               Predictor          OR         SE        95% CI                 p           OR            SE        95% CI                           p
                                                       LL         UL                                              LL         UL
Step 1         Ethnicitya         0.48       0.50      0.18       1.28        0.14        49.05         2.36      0.48       5046.28               0.10
               Genderb            0.70       0.54      0.24       2.01        0.51        0.01          2.51      0.00       1.62                  0.08
Step 2         AMI                1.05       0.02      1.02       1.09
J. Racial and Ethnic Health Disparities

that the IO factor highlights the in-group and family unit, it is   Limitations and Future Directions
possible that these values are more salient and more directly
relevant to mental health behaviors than broader cultural goals     Our findings should be interpreted with several limitations in
in college students (extended discussion of the factor analysis     mind. First, the ethnic demographic makeup of our university
and cultural values scales alone is available in the supplemen-     (33.8% Asian, 41.5% Latinx) is not representative of the larg-
tary text).                                                         er US population (5.9% Asian, 18.5% Latinx) [64] and thus
                                                                    our findings may not be reflective of broader Asian and Latinx
                                                                    experiences—that is, those participating in our study are
Shared Cultural Values, Perceived Need, and Help-                   surrounded by more diverse cultural feedback than the aver-
Seeking                                                             age Asian or Latinx youth might be. Moreover, it is important
                                                                    to note that both ethnic groups are heterogeneous, and thus
In the current study, we observed that students who                 students may have varied more in their experiences and ad-
scored highly on our IO factor were less likely to endorse          herence to broad Asian or Latinx values specifically, which
needing mental health treatment, over and above ethnicity           adds to our efforts to look broadly at shared themes rather than
and their mental health attitudes. In interpreting this find-       values specific to any one group. Second, college environ-
ing, it is important to consider research showing that fam-         ments have uniquely accessible on-campus counseling centers
ilism and group-orientation, two subcomponents of IO,               with flexible service delivery and payment options, staffed by
can act as protective factors for mental health [14]. In            mental health professionals with specialized training to work
particular, group-oriented attitudes, such as a greater             with college youth and motivated to reach students. Thus, the
sense of pride and belonging to one’s ethnic group, have            mental health environment of college campuses does not ac-
been linked to a decreased likelihood of psychiatric ser-           curately capture off-campus mental health experiences or oth-
vice use in Latinx adults and decreased odds of lifetime            er types of mental health help that Asian and Latinx youth
psychiatric diagnoses for both Asian and Latinx adults              receive. Third, given that only those students who indicated
[62, 63]. It is possible that students in our sample with           mental health treatment need reported on help-seeking behav-
higher IO experience the benefits of familism and in-               iors, we were underpowered in predicting help-seeking
group orientation in having a greater support network               behaviors—only 33 participants responded to this question.
and may thus be in lesser need of mental health services.           It is possible that students were reluctant to self-report on
However, in light of our finding that greater IO also pre-          needing and seeking treatment, even though their answers
dicted negative mental health attitudes, an alternative in-         were anonymized. Including implicit measures of emotional
terpretation is that IO might encourage underreported or            health to complement self-report may further our understand-
under-perceived need for help, on which critically impor-           ing of the broader sociocultural contexts in which youth de-
tant help-seeking behavior is contingent. This association          velop [65]. Lastly, this was a cross-sectional study; a longitu-
was not observed with our CO factor. An important di-               dinal design examining the interplay between interdependent
rection for future research will be to explicitly arbitrate         cultural value endorsement, mental health attitudes, and help-
between these possibilities. Our initial data from a fairly         seeking behavior over time would provide insights into the
large and diverse college sample indicate that probing              direction of effects of these variables.
underlying shared cultural values, irrespective of ethnici-             Given the nuanced role that interdependent cultural values
ty, may be informative for university mental health ser-            play in emotional well-being, it will be important to examine
vice providers. We therefore contend that probing cultural          circumstances under which these group-oriented values may
values when assessing students’ mental health needs is              be beneficial or detrimental to mental health attitudes and
more in line with students’ lived experiences than relying          behaviors. Under a cultural value-based approach, values that
on ethnic background alone.                                         may otherwise seem irrelevant may actually hold
    Notably, IO inversely predicted perceived need, whereas         significance—that is, it is important to strike a balance be-
the LVS alone did not, even though the IO factor was largely        tween understanding how individuals uniquely perceive their
comprised of LVS items. We note that neither the retained           cultures and also considering intersectionality and inter-group
AVS-R or LVS items separately were predictive of any out-           similarities. For instance, research might probe whether great-
comes of interest. As such, the IO factor contributed beyond        er adherence to Interdependent Orientation predicts negative
the role of AVS and LVS examined separately and may thus            mental health attitudes and mental health behaviors in other
be more relevant for predicting mental health behaviors in our      ethnic groups as well. Additionally, though the current work
sample. Our data indicate that probing underlying values that       identified similarities in internal barriers to help-seeking be-
have been typically associated with specific ethnic groups          haviors across groups, we are in no way stating that structural
outside of the bounds of ethnicity and culture may be infor-        barriers, such as diminished access to resources, or cost, are
mative for university mental health service providers.              irrelevant to mental health behaviors in ethnic minority youth.
J. Racial and Ethnic Health Disparities

We would also like to caution against an automatic preference                  Declarations
for considering professional psychological services as the ide-
al method of support for mental health. Nonetheless, behav-                    Ethics Approval This study was approved by the University of
                                                                               California Institutional Review Board (IRB).
ioral health services are the main source of mental health sup-
port offered by colleges and universities. As such, it is impor-
                                                                               Informed Consent Informed consent was obtained from all individual
tant to better understand why some students might not be                       participants included in the study.
engaging with these available services. If specific cultural
values are leading students to underutilize campus mental                      Conflict of Interest The authors declare no competing interests.
health resources but perhaps engage in other types of help-
seeking, then it is important to identify what alternative
methods of support might look like. Doing so would also                        References
inform outreach programs to bring awareness to alternative
resources available for student mental health. Future studies                   1.   Lipson SK, Lattie EG, Eisenberg D. Increased rates of mental
                                                                                     health service utilization by U.S. college students: 10-year popula-
might build upon our findings and examine interactions be-
                                                                                     tion-level trends (2007-2017). Psychiatric Services. 2018;70(1):
tween cultural values and resource availability. Next steps                          60–3.
might focus on further parsing out the multifaceted experience                  2.   Chen JA, Stevens C, Wong SHM, Liu CH. Psychiatric symptoms
of familism, taking a strength-based perspective in under-                           and diagnoses among U.S. college students: a comparison by race
standing when strong adherence to interdependent values                              and ethnicity. Psychiatric Services. 2019;70(6):442–9. https://doi.
may act as a buffer for mental health problems and the stresses                 3.   Hunt JB, Eisenberg D, Lu L, Gathright M. Racial/ethnic disparities
unique to the university environment. By doing so, re-                               in mental health care utilization among U.S. college students: ap-
searchers may utilize and amplify the positive effects of forces                     plying the Institution of Medicine definition of health care dispar-
already in play rather than “culture-blaming.”                                       ities. Academic Psychiatry. 2015;39(5):520–6.
                                                                                4.   Downs MF, Eisenberg D. Help seeking and treatment use among
                                                                                     suicidal college students. Journal of American College Health.
Conclusions                                                                          619611.
                                                                                5.   Lipson SK, Kern A, Eisenberg D, Breland-Noble AM. Mental
                                                                                     health disparities among college students of color. The Journal of
Asian and Latinx college students exhibit similarly low rates                        Adolescent Health. 2018;63(3):348–56.
of mental health help-seeking behaviors, yet little work has                         jadohealth.2018.04.014.
examined what value-based similarities both groups might                        6.   Leong FT, Kalibatseva Z. Cross-cultural barriers to mental health
share that may contribute to these behavioral outcomes. The                          services in the United States. Cerebrum. 2011:5 http://www.ncbi.
current study sought to test whether shared cultural values
                                                                                7.   McGuire TG, Miranda J. Racial and ethnic disparities in mental
influence mental health help-seeking behaviors in ethnic mi-                         health care: evidence and policy implications. Health Affairs.
nority students outside ethnic group membership alone. We                            2008;27(2):393–403.
focused on cultural values typically associated with specific                   8.   Miranda R, Soffer A, Polanco-Roman L, Wheeler A, Moore A.
ethnicities and considered the possibility of shared cultural                        Racial/ethnic minority versus white young adults 6 months after
                                                                                     intake at a college counseling center. Journal of American
values of diverse students together rather than separately.                          College Health. 2014;63(5):291–8.
Our findings showed that Asian and Latinx students share                             07448481.2015.1015024.
values surrounding family, group, and culture. Further, their                   9.   Ohtani A, Suzuki T, Takeuchi H, Uchida H. Language barriers and
interdependent values influenced their attitudes towards men-                        access to psychiatric care: a systematic review. Psychiatric
tal health and influenced their perception of their own mental                       Services. 2015;66(8):798–805.
health treatment needs, a key step in seeking mental health                    10.   Kim BS, Atkinson DR, Umemoto D. Asian cultural values and the
help. Our findings shed light on the attitudes and behaviors                         counseling process: current knowledge and directions for future
regarding mental health help-seeking among both Asian and                            research. The Counseling Psychologist. 2001;29(4):570–603.
Latinx students and may inform future interventions and ser-               
                                                                               11.   Eghaneyan BH, Murphy ER. Measuring mental illness stigma
vices in university contexts.
                                                                                     among Hispanics: a systematic review. Stigma and Health.
                                                                               12.   Silva A, Campos B. Familism. The Blackwell Encyclopedia of
Supplementary Information The online version contains supplementary                  Sociology. 2019:1–6.
material available at                    wbeos1188.
                                                                               13.   Choi Y, Kim TY, Noh S, Lee J, Takeuchi D. Culture and family
Acknowledgements We thank Julia Slane for her contributions towards                  process: measures of familism for Filipino and Korean American
the data collection process and Dr. Esra Kurum for her statistical expertise         parents. Family Process. 2018;57(4):1029–48.
and comments on the analysis portion of the manuscript.                              1111/famp.12322.
J. Racial and Ethnic Health Disparities

14.   Campos B, Ullman JB, Aguilera A, Dunkel Schetter C. Familism                 International Journal for the Advancement of Counselling.
      and psychological health: the intervening role of closeness and              2011;33(4):266–79.
      social support. Cultural Diversity and Ethnic Minority                   30. Interian A, Martinez IE, Guarnaccia PJ, Vega WA, Escobar JI. A
      Psychology. 2014;20(2):191–201.                     qualitative analysis of the perception of stigma among Latinos re-
      a0034094.                                                                    ceiving antidepressants. Psychiatric Services. 2007;58(12):1591–4.
15.   Li Y. Intergenerational conflict, attitudinal familism, and depressive
      symptoms among Asian and Hispanic adolescents in immigrant               31. Kung WW. Cultural and practical barriers to seeking mental health
      families: a latent variable interaction analysis. Journal of Social          treatment for Chinese Americans. Journal of Community
      Service Research. 2014;40(1):80–96.                 Psychology. 2004;32(1):27–43.
      01488376.2013.845128.                                                        10077.
16.   Juang LP, Nguyen HH. Ethnic identity among Chinese-American              32. Senft N, Campos B, Shiota MN, Chentsova-Dutton YE. Who em-
      youth: the role of family obligation and community factors on eth-           phasizes positivity? An exploration of emotion values in people of
      nic engagement, clarity, and pride. Identity. 2010;10(1):20–38.              Latino, Asian, and European heritage living in the United States.                                   Emotion. Advance online publication. 2020.
17.   Steidel AGL, Contreras JM. A new familism scale for use with                 1037/emo0000737.
      Latino populations. Hispanic Journal of Behavioral Sciences.             33. Hampton NZ, Sharp SE. Shame-focused attitudes toward mental
      2003;25(3):312–30.                 health problems: the role of gender and culture. Rehabilitation
18.   Caplan S. Intersection of cultural and religious beliefs about mental        Counseling Bulletin. 2014;57(3):170–81.
      health: Latinos in the faith-based setting. Hispanic Health Care             0034355213501722.
      International. 2019;17(1):4–10.                 34. Kramer EJ, Kwong K, Lee E, Chung H. Cultural factors influencing
      1540415319828265.                                                            the mental health of Asian Americans. Western Journal of
19.   Fogel J, Ford DE. Stigma beliefs of Asian Americans with depres-             Medicine. 2002;176(4):227–31.
      sion in an internet sample. The Canadian Journal of Psychiatry.          35. Han M, Pong H. Mental health help-seeking behaviors among
      2005;50(8):470–8.                Asian American community college students: the effect of stigma,
20.   Ishikawa RZ, Cardemil EV, Falmagne RJ. Help seeking and help                 cultural barriers, and acculturation. Journal of College Student
      receiving for emotional distress among Latino men and women.                 Development. 2015;56(1):1–14
      Qualitative Health Research. 2010;20(11):1558–72. https://doi.               0001.
      org/10.1177/1049732310369140.                                            36. Mendoza H, Masuda A, Swartout KM. Mental health stigma and
                                                                                   self-concealment as predictors of help-seeking attitudes among
21.   Chang J, Natsuaki MN, Chen CN. The importance of family factors
                                                                                   Latina/o college students in the United States. International
      and generation status: mental health service use among Latino and
                                                                                   Journal for the Advancement of Counselling. 2015;37(3):207–22.
      Asian Americans. Cultural Diversity and Ethnic Minority
      Psychology. 2013;19(3):236–47.
                                                                               37. Nolle AP, Gulbas L, Kuhlberg JA, Zayas LH. Sacrifice for the sake
                                                                                   of the family: expressions of familism by Latina teens in the context
22.   Villatoro AP, Morales ES, Mays VM. Family culture in mental
                                                                                   of suicide. The American Journal of Orthopsychiatry. 2012;82(3):
      health help-seeking and utilization in a nationally representative
      sample of Latinos in the United States: The NLAAS. The
                                                                               38. Miville ML, Constantine MG. Cultural values, counseling stigma,
      American Journal of Orthopsychiatry. 2014;84(4):353–63. https://
                                                                                   and intentions to seek counseling among Asian American college
                                                                                   women. Counseling and Values. 2007;52(1):2–11.
23.   Sanchez AR, Atkinson DR. Mexican-American cultural commit-                   10.1002/j.2161-007X.2007.tb00083.x.
      ment, preference for counselor ethnicity, and willingness to use         39. Shea M, Yeh CJ. Asian American students’ cultural values, stigma,
      counseling. Journal of Counseling Psychology. 1983;30(2):215–                and relational self-construal: correlates and attitudes toward profes-
      20.                              sional help seeking. Journal of Mental Health Counseling.
24.   Gim RH, Atkinson DR, Whiteley S. Asian-American acculturation,               2008;30(2):157–72.
      severity of concerns, and willingness to see a counselor. Journal of         g662g5l2r1352198.
      Counseling Psychology. 1990;37(3):281–5.             40. Kim JE, Zane N. Help-seeking intentions among Asian American
      1037/0022-0167.37.3.281.                                                     and White American students in psychological distress: application
25.   Atkinson DR, Gim RH. Asian-American cultural identity and atti-              of the health belief model. Cultural Diversity and Ethnic Minority
      tudes toward mental health services. Journal of Counseling                   Psychology. 2016;22(3):311–21.
      Psychology. 1989;36(2):209–12.                 cdp0000056.
      0167.36.2.209.                                                           41. Rao D, Feinglass J, Corrigan P. Racial and ethnic disparities in
26.   Corrigan PW, Rao D. On the self-stigma of mental illness: stages,            mental illness stigma. The Journal of Nervous and Mental
      disclosure, and strategies for change. Canadian Journal of                   Disease. 2007;195(12):1020–3.
      Psychiatry. 2012;57(8):464–9.                       0b013e31815c046e.
      070674371205700804.                                                      42. Whaley AL. Ethnic and racial differences in perceptions of danger-
27.   Latalova K, Kamaradova D, Prasko J. Perspectives on perceived                ousness of persons with mental illness. Psychiatric Services.
      stigma and self-stigma in adult male patients with depression.               1997;48(10):1328–30.
      Neuropsychiatric Disease and Treatment. 2014;10:1399–405.                43. Canino G. Are somatic symptoms and related distress more preva-                                          lent in Hispanic/Latino youth? Some methodological consider-
28.   Eisenberg D, Downs MF, Golberstein E, Zivin K. Stigma and help               ations. Journal of Clinical Child and Adolescent Psychology.
      seeking for mental health among college students. Medical Care               2004;33(2):272–5.
      Research and Review. 2009;66(5):522–41.         44. Grover S, Ghosh A. Somatic symptom and related disorders in
      1077558709335173.                                                            Asians and Asian Americans. Asian Journal of Psychiatry.
29.   Masuda A, Boone MS. Mental health stigma, self-concealment, and              2014;7(1):77–9.
      help-seeking attitudes among Asian American and European                 45. Ryder A, Yang J, Heine S. Somatization vs. psychologization of
      American college students with no help-seeking experience.                   emotional distress: a paradigmatic example for cultural
J. Racial and Ethnic Health Disparities

    psychopathology. Online Readings in Psychology and Culture.                Counseling Psychology. 1999;46(3):342–52.
    2002:10(2).                        1037/0022-0167.46.3.342.
46. Comas-Díaz L. Latino healing: the integration of ethnic psychology     57. Kim BSK, Soliz A, Orellana B, Alamilla SG. Latino/a Values
    into psychotherapy. Psychotherapy: Theory, Research, Practice,             Scale: development, reliability, and validity. Measurement and
    Training. 2006;43(4):436–53.            Evaluation in Counseling and Development. 2009;42(2):71–91.
47. Hwang WC, Wood JJ, Lin K-M, Cheung F. Cognitive-behavioral             58. Wolff G, Pathare S, Craig T, Leff J. Community attitudes to mental
    therapy with Chinese Americans: research, theory, and clinical             illness. The British Journal of Psychiatry. 1996;168(2):183–90.
    practice. Cognitive and Behavioral Practice. 2006;13(4):293–303.                            59. Evans-Lacko S, Little K, Meltzer H, Rose D, Rhydderch D,
48. Leong FT, Lau AS. Barriers to providing effective mental health            Henderson C, et al. Development and psychometric properties of
    services to Asian Americans. Mental Health Services Research.              the reported and intended behaviour scale (RIBS): a stigma-related
    2001;3(4):201–14.                 behaviour measure. Cambridge University Press. 2011;20(3):263–
49. Nguyen QCX, Anderson LP. Vietnamese Americans’ attitudes to-               71.
    ward seeking mental health services: Relation to cultural variables.   60. TNS BMRB. Attitudes to Mental Illness 2013 Research Report,
    Journal of Community Psychology. 2005;33(2):213–31. https://doi.           Prepared for Time to Change. London: TNS BMRB; 2014.
    org/10.1002/jcop.20039.                                                61. Abdullah T, Brown TL. Mental illness stigma and ethnocultural
50. Liang J, Matheson BE, Douglas JM. Mental health diagnostic con-            beliefs, values, and norms: an integrative review. Clinical
    siderations in racial/ethnic minority youth. Journal of Child and          Psychology Review. 2011;31(6):934–48.
    Family Studies. 2016;25(6):1926–40.               cpr.2011.05.003.
                                                                           62. Burnett-Zeigler I, Bohnert KM, Ilgen MA. Ethnic identity, accul-
51. Goldston DB, Molock SD, Whitbeck LB, Murakami JL, Zayas LH,
                                                                               turation and the prevalence of lifetime psychiatric disorders among
    Hall GCN. Cultural considerations in adolescent suicide prevention
                                                                               Black, Hispanic, and Asian adults in the U.S. The Journal of
    and psychosocial treatment. The American Psychologist.
                                                                               Psychiatric Research. 2012;47(1).
52. Okazaki S. Treatment delay among Asian-American patients with
                                                                           63. Burnett-Zeigler I, Lee Y, Bohnert KM. Ethnic identity, accultura-
    severe mental illness. American Journal of Orthopsychiatry.
                                                                               tion, and 12-month psychiatric service utilization among Black and
                                                                               Hispanic adults in the U.S. The Journal of Behavioral Health
53. Satcher D. Mental health: a report of the Surgeon General–
                                                                               Services & Research. 2018;45(1):13–30.
    Executive summary. Professional Psychology: Research and
    Practice. 2000;31(1):5–13.
    1.5.                                                                   64. U.S. Census Bureau (2019). QuickFacts United States. Retrieved
54. U.S. Census Bureau (2019). QuickFacts California. Retrieved from           from                       65. Michalska KJ, Davis EL. The psychobiology of emotional devel-
55. Kim BSK, Hong S. A psychometric revision of the Asian Values               opment: the case for examining sociocultural processes.
    Scale using the Rasch Model. Measurement and Evaluation in                 Developmental Psychobiology. 2019;61(3):416–29. https://doi.
    Counseling and Development. 2004;37(1):15–27.             org/10.1002/dev.21795.
56. Kim BSK, Atkinson DR, Yang PH. The Asian Values Scale: de-             Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
    velopment, factor analysis, validation, and reliability. Journal of    tional claims in published maps and institutional affiliations.
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